Jaymazing Posted January 23, 2013 Author Share Posted January 23, 2013 I'd like to give him a good fluid bolus The ekg is looking like a base of atrial flutter in leads 2 & 3 and V5 V3 is making it look kind of like a low/lateral wall infarct with early repolatization... but I tend to suck at 12 leads so I may be completely off at this one... Either way some fluid would be good and transport with a possible helo ride waiting for transfer to the city ? The stuff that looks like flutter waves, just so you know, is artifact. Can I ask what the fluid bolus is for? and how much you'd like to give? Sounds like a call I did but was a 79 yr old female. Treated as cadiac ended up as a hernia around the chest cavity, near the heart. That's really interesting! What's that called? I haven't heard of that before Link to comment Share on other sites More sharing options...
MariB Posted January 23, 2013 Share Posted January 23, 2013 Fluid always good, plus you have a line in for future possible need. Im not a paramedic, but know many that like to get fluid running and a line in for any high suspicion cases Link to comment Share on other sites More sharing options...
Jaymazing Posted January 23, 2013 Author Share Posted January 23, 2013 Fluid always good, plus you have a line in for future possible need. Im not a paramedic, but know many that like to get fluid running and a line in for any high suspicion cases That's interesting. Actually, the ideology that "fluid is always good" has been going out the door for a while now. But I do agree that it's preferred to have a line established in case this patient crashes or needs meds. However, you only want to give them just enough fluid to keep the vein open (TKVO). The reason behind this is that, like all drugs (and yes, saline is a drug), giving too much of it or giving it when it isn't needed can be detrimental to the patients health and worsen outcomes. The days of bolusing every questionable patient are far behind us; you have to have a reason to give it if your going to give it. Some reasons why this patient doesn't need a bolus; his pressure is 114/76, he's not showing signs of hypovolemia, and he is showing signs of cardiac decompensation, which means that he's highly vulnerable to fluid overload, and would likely not benefit from having salt water dumped into his body. However, I would gladly accept that it is appropriate to establish intravenous access on this patient Link to comment Share on other sites More sharing options...
Kiwiology Posted January 23, 2013 Share Posted January 23, 2013 Fluid always good, plus you have a line in for future possible need. Im not a paramedic, but know many that like to get fluid running and a line in for any high suspicion cases Respectfully, wrong. Fluid is not always good, intravascular volume expansion has a specific purpose with specific indications which are specific to that patient, if they are not met then do not give it. Get him off the non rebreather mask; put him on a nasal cannula. Like fluid, oxygen is not always "good to have" and appears to make mortality in patients with acute coronary syndrome / myocardial infarction worse. Does his chest pain get significantly better / go away and/or does his ST depression resolve with GTN administration? If either of these are the case, and then they come back, I would give him more GTN but if neither of these are the case then I would not give any further GTN. The ECG looks like some ST depression in the inferior leads with reciprocal ST elevation in V4 and V5? The rhythm strip shows quadrageminal PVC. No further treatment apart from GTN if appropriate and some analgesia as required. If his chest pain significantly improved with GTN then he has no immediate life threat and is not time critical (status 3) however if not then he is time sensitive (but not time critical) and has a possible threat to his life (status 2). Normal transport. 1 Link to comment Share on other sites More sharing options...
Jaymazing Posted January 23, 2013 Author Share Posted January 23, 2013 Get him off the non rebreather mask; put him on a nasal cannula. Like fluid, oxygen is not always "good to have" and appears to make mortality in patients with acute coronary syndrome / myocardial infarction worse. You put him on the NC, and he tolerates it quite well. His Sp02 remains at 94%, and he denies any shortness of breath. Does his chest pain get significantly better / go away and/or does his ST depression resolve with GTN administration? If either of these are the case, and then they come back, I would give him more GTN but if neither of these are the case then I would not give any further GTN. Upon administering nitro twice, his discomfort and condition remain unchanged. The 12 lead is repeated, and it remains identical. The ECG looks like some ST depression in the inferior leads with reciprocal ST elevation in V4 and V5? The rhythm strip shows quadrageminal PVC. Would you say that these are R-on-T PVC's? No further treatment apart from GTN if appropriate and some analgesia as required. If his chest pain significantly improved with GTN then he has no immediate life threat and is not time critical (status 3) however if not then he is time sensitive (but not time critical) and has a possible threat to his life (status 2). Normal transport. He refuses all narcotic pain killers. He states "I don't want to get addicted, like those people on TV" Link to comment Share on other sites More sharing options...
Kiwiology Posted January 23, 2013 Share Posted January 23, 2013 What about if we change trom an NC to an acute (ordinary) oxygen mask does his SpO2 increase? Whatever the lowest possible flow we can use to achieve an SpO2 > 96% then lets do that. If his discomfort and ECG remain unchanged then no further GTN In the first instance I would offer him some entonox, if he doesn't want it (or any other pain relief) then that is fine, don't give it to him Link to comment Share on other sites More sharing options...
craig Posted January 23, 2013 Share Posted January 23, 2013 I concur with Kiwi to an extent,,,,,,,however I would have gone to a normal O2 therapy mask before the nasal cannula The patient states he should go to the hospital because apparently he is an a@@hole now.........FACT is he was an a@@hole before his wife called you.......... 1 Link to comment Share on other sites More sharing options...
Kiwiology Posted January 23, 2013 Share Posted January 23, 2013 I think this bloke might be having NSTEMI If the GTN is not making his pain significantly better or resolving the ST depression then I reckon he probably has some sort of non occlusive thrombus. I would be interested to see what his enzymes e.g. Trop-T / CKmb and angipgraphy have to say for themselves Link to comment Share on other sites More sharing options...
Arctickat Posted January 23, 2013 Share Posted January 23, 2013 Yeah, all i'd add to this is a c/tnI and myoglobin test. Link to comment Share on other sites More sharing options...
Jaymazing Posted January 23, 2013 Author Share Posted January 23, 2013 Well I don't know if there's anywhere else to go with this scenario. In real life, this was his next ECG:http://sphotos-a.ak.fbcdn.net/hphotos-ak-snc6/166588_10152477195835026_1562051472_n.jpg Link to comment Share on other sites More sharing options...
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